A Descriptive Study to Acess the Knowledge Of

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

GITTY GEORGE

ST 1. Name of the candidate and address 1 YEAR M.Sc NURSING ROYAL COLLEGE OF NURSING 7th MAIN ROAD, 1ST BLOCK. UTTARAHALLI, BANGALORE 61.

2. Name of the Institution Royal College Of Nursing

3. Course of study and subject 1st Year M.Sc Nursing, Obstetrics And Gynaecological Nursing.

4. Date of admission to course 30.06.2008

5. Title of the topic A Descriptive Study To Assess The Knowledge And Practice Regarding Obstetrical Emergencies Management Among Staff Nurses In Vanivillas Hospital, Bangalore.

6. BRIEF RESUME OF THE INDENDED WORK

INTRODUCTION:

1 “Birth and death are not two different states, But they are different aspects of the same state there is a little reason to deplore the one there is to be pleased over the other.” -Mahthma Gandhi

Death is has been quite clear and has not changed through out the ages, Death is and has so far been, that stage in which a person’s body can no longer perform any useful or important activities . Death the permanent and all life functions is an organism or a part of an organism. Death the time when something ends and birth is the time when something begins. The Obstetrical Emergencies are the leading cause of death in most of the developed and developing countries. In 1921 there was little provision for the care of the pregnant women in Northern Ireland where there were only two Hospitals staffed by specialist Obstetricians.

The mortality statistics reflected this, the province having the highest maternal mortality and second highest infant mortality rate in the United Kingdom.There was a little progress until the establishment of the National health services 1948. With in a short period of time excellent Hospital speciality and domiciliary midwifery services are developed. In 1970’s there are more advancement occurs and the general practitioner services were disappeared. The maternal mortality is now zero and the perinatal mortality 8 per 1,000 births .

The investigators reports a retrospective observational study carried out a teritiary referral maternity unit will helps to improve the maternal and child health. Obstetrical Emergencies are life threatening medical condition that occurs in pregnancy during or after labour and pregnancy. T he Intrapartum emergencies are challenging to all perinatal nurses because of increased risk of adverse outcome for the mother and foetus. There are number of illness and disorders of pregnancy that can threaten the well being of mother and child. Perinatal emergencies such as seizures, amniotic fluid embolus, hemorrhage and uterine rupture, create physiological challenges and trigger intrinsic survival techniques.1

The aim of the protocol in obstetrical Emergencies is to find the causes to understand the pathophysiological changes as a result from the emergency complications. The availability of obstetrical management protocols provide better and more harmonized obstetrical and medical care.If we desire to improve our Obstetrics results, the high risk cases should be identified and given proper Antenatal, Intranatal and neonatal care. But in general they need not be admitted to specialized centers and their care can be left to properly trained midwives and medical officers in health centre or general practitionals. The services of trained community health worker and assistant nurse of health centre should be screening in rural areas, urban and semi-urban areas.

6.1 NEED FOR STUDY:

2 In developing countries a high rate of maternal, Infant and neonatal mortality which is partially due to the lack of health care in most pregnancies. The greater that 90% of women in many rural District of Nepal deliver at home with no health care workers present. Delivers are often unhygienic and follow a pregnancy with no prenatal care.2

All the pregnancies and deliveries are potentially at risk. However there are certain categories of pregnancies where the mother , the fetus, or neonate is in a state of increase jeopardy. About 20-30% of pregnancies belongs to their category. If we desire to improve obstetrical result, this group must be identified and gain extra care and this group is responsible for 70-80% of perinatal mortality and morbidity. In the developed countries the maternal mortality and morbidity should be brought down by the proper identification of high risk cases .But in developing countries with a maternal and perinatal mortality, the maternal factors should also be considered. It must be remembered that over 50% of maternal complications and 60% of all primary caesarian sections arise from the high risk group of nurses.3.

From 327 in 1996 to 675 in 1999 more than 76% of the women spent 48hrs or less from time of admission to the death and majority of them were low parity, nulliparity was 37.5%. Young women 20-39 years old accounted for 81.3% with 9.4% teenage death due to illegally abortion. The maternal mortality rate increased progressively from 325 in 1996 to peak at 765 in 1999 and it was lowest in 2000.4

A retrospective study of maternal death in Malasia in the year 1995-1996 was 20.6%. The proportion of mothers who had no obstetrical risk factors in pregnancy that leads to death was 16.8%.5

According to WHO estimates, about 510,000 maternal death (about 0.9 percent of total deaths) occurred globally during the year 2002. Of these death about 231,000 occurred in African countries, 17,000 in Americans, 68,000 in European, 171,000 in South East Asia and 21,000 in western pacific countries. In the least developed countries the chances are about 1 in 16.In the developing countries about 1in 60 and in industrialized countries about 1 in 4,000. In Sub- Saharan Region the chances are very high with about 1 in 13 pregnancies. In India among those countries which are very high maternal mortality rate. It was 20 per 1000 live birth in 1938 and declined to 10 per 1000 live birth by 1959. According to RGI estimates for the year 2000, maternal mortality rate for India was 407 per 1,00,000 live births. The trend has not changed significantly in the last 5 years. This mean more than 1,00,000 women die each year due to pregnancy related cause. It is mainly due to large number of deliveries conducted by untrained persons. 6

3 Chaudhuri N, Pal s, Rov A conducted the studies in a rural based hospital where most of the mother came without any antenatal care ,from November 1979 to December 1980 to observe the mortality pattern in different type of delivery. Only live born babies were included in the study in which the mortality rate in elective cesarean section was found to be nearly equal to that in vaginal delivery. The percentage of mortalitywas higher (5- 4%) in emergency cesarean section the chief causes being asphyxia neonatrum, low gestational age and low birth weight.7

Saizonouj, godin I, Quendo EM, Zerbo R,Derjardin did a study to evaluate emergency obstetric care and the perceptions and expectations of women who experienced “near miss” events to improve maternal health in Benin. The total sample size was 557 women. The questionnaire and interview was conducted to collecting the data. The result result reveals that the current maternal system fails to effectively deal with obstetric complications. It needs to be better resourced , more easily available, cheaper and take into account the women’s needs.8

A qualitative study to assess the emergency obstetrical care in Bangladesh .The setting was on the large government medical college hospital in Bangladesh. The samples are the provider and the users of emergency obstetric care. Ethnographic observation in obstetric unit including interviews with the staff and women using the unit and their carers are the method used for the study. The researcher concluded that the greater consideration must be given to what happens at health facilities to ensure that 1)Using emergency does not further improves the families and 2)The ability to pay does not influences treatment .Developing alternative finance mechanism to reduce the burden of out of pocket expenses is crucial but challenging.9

Since the investigator worked as a staff nurse in a hospital, it was found that staff nurses are not practicing emergency obstetrical management during labour in the maternity ward. So this will cause and increase the chance for the occurrence of maternal mortality and morbidity.

Many studies proved that the nurses are not having adequate knowledge regarding obstetric emergencies control protocols. So the researcher thought of taking the task of assessing the knowledge and practice of staff nurses and helping them to improve their knowledge regarding obstetrical emergencies in order to reduce the further incidence in the Hospital.

6.2 REVIEW OF LITERATURE

4 The review of literature helps to summarize the knowledge and practice based for a conducting study. It also summarize the current knowledge about a particular practice problem including what is known and what is not known about the problem. The scope of literature review should be broad enough to allow the reader to become familiar with the research problems and narrow enough to include predominantly relevant sources.10

A study to determine the most effective method of delivering training to staff on the management of obstetrical emergency. The research was conducted inDistrict General Hospital in U.K delivering approximately 3500 women per year. The samples was 36 staff, including the junior and senior medical and midwifery staff. There are three teaching method were employed. The team knowledge and performance were assessed pre-training, post- training, and at three months later. The study revealed that all the team member improved their performance and knowledge .Obstetrics is a high risk specially in which the emergencies are to some extent, Training staff to manage emergencies is a fundamental principles of risk management. Simulation based training is an appropriate proactive approach to reducing errors and risks in obstetrics, improving team work and communication giving the students a multiplicity of transferable skill to improve their performance.11

A descriptive study used for the training of labour ward personnel in a acute obstetrical emergencies, in labour ward personnel at labour ward, Department obstetrics, John Rad cliffe Hospital Oxford,UK. The questionarre method was used to collect data.The study concluded that with regard to training in acute obstetric emergencies, few training programme have been described and even fewer have been evaluated. The training method need to be developed, described and evaluated, further well-conducted research for the important intervention is urgently required.12

A study to evaluate the simulation based curriculum unit for labour and delivery teams involved in obstetrical emergencies to detect and address the common mistakes. 88 Midwives are taken as a sample for the study .The setting was on his maternity Hospital; Israel, after check list of the action expected from the team were handed out of to the courses tutors who observed the “Event”. The result reveals that the common management errors was delay in transporting the bleeding patient to operating room(82%) unfamiliarity with prostaglandin to reverse uterine atony (81%), poor cardiopulmonary resuscitation techniques (80%), inadequate documentation of shoulder dystocia (80%) delayed administration of blood products to reserve consumption coagulopathy (66%) and inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction 32%.So the researcher concluded that curricular unit based on simulation of obstetric emergencies can identify pit falls of management in labour and delivery room.13

A study to assess the knowledge of skilled attendant regarding the managing obstetrical emergencies and trauma structured skill training in Armenia, utilizing models and reality based scenarios.The setting was on 5 Academic department of obstetric and gynecology, north staff or dshine hospital trust UK. The availability of skilled attendance to prevent, detect and manage obstetrical complications may be the single most important factor in preventing maternal death. There must be a training progrramme was established. The questionnaire method was used to collect the data. The study concluded that the reliability of the model based scenarios with a highly significant improvement in obstetrical emergency management. However a clinical audit will be required to measure the full impact of training by longer term follow up.14

A cohort observational study to evaluate the obstetrical emergency care improves the neonatal outcomes. The samples are the term , cephalic presenting single ton infant born at 1998 and 2003.The setting of the study was the south med hospital, university of Bristol, UK. The method for the study was five minitues Apgar score was reviewed. The study reveals that the five minitue Apgar score decreases from 86.4 to 44.6% and those with HIE decreased from 27.3 to 13.6% following the introduction of the training courses in 2000.The study concluded that the introduction of obstetrical emergencies training courses was associated with a significant reduction low five minitue Apgaar score HIE. This improvement has been sustained by the training has continued. This is the first time an educational intervention has been shown to be associated with clinical important and the improvement in perinatal outcome.15

A retrospective study to evaluate the incidence of unbooked obstetric emergency cases increases the maternal mortality. The settings were the maternity ward, university of Nigeria Teaching Hospital, Nigeria between January 1966 and December 1999.The samples are the 435 cases of emergency obstetrics .The study concluded that 40% of total maternal mortality in the hospital were attributed of unbooked cases with hemorrhage and sepsis is the major cases Also the peri-natal mortality of 40.2% was recorded. The lack of basic education and poverty are the major identifiable risk factors. Improving health care facilities, female education, Regular training courses of medical personnels will help to reduce the maternal mortality.16

A study to evaluate the obstetricians willingness to practice collaboratively with the midwifes. The setting was on the National Taipei college of nursing, Taiwan. The samples are 78 physicians. The method is used for collecting the data by the questionnaire and four open-ended questions. The study reveals that all the obstetricians were unwilling to work collaboratively with midwifes. The result shows that if the midwifery education was to be advanced to college level ,the degree of willingners to work collaboratively with the midwives improved significantly. The reason for unwillingness is because of the incapability of midwifes .The advancing and enhancing midwifery education in Taiwan should be the first step to raise the profile of midwifes and the midwifery profession. It would improve the quality of care provided to women and their infants and consequently improve the health and social wellbeing of present and future generation.17 6 A study to evaluate the effectiveness of simulation training for shoulder dystocia management and compare training using a high-fidelity mannequin with that of traditional devices. The setting was on the South mead Hospital, university of Bristol, UK. The samples are 45 doctors and 95 midwives (a total of 140 praticipants). The performance was assessed by pre and post training using videoded, standardized shoulder dystocia simulation. 132 participants completed post-training assessment. All the training was associated to improve the performance. The researcher find out that the out of 139, 79 have good communication with the patient, pre-and post training. The training with high-fidelity mannequin was associated with a higher successful delivery rate than training with traditional devices. The study verified the need for shoulder dystocia training, before training only 43% participants could achieve delivery. All the training of high-fidelity mannequin includes force perception teaching offered additional training benefits.18

A study to evaluate the effectiveness of training in multi professional emergency medicine in primary health care among practitioner, ambulance personnel and primary health care nurses Norwegian Hospital in Northern Norway. The samples for the training program are 22 teams and 145 participants. They are conducted the training program has to modify the training concept for use in general practice and strengthen acute medical competence. The multi professional training courses were held in 10 muncipalites. Communication, leadership and co- operation was emphasized during the training. The individual questionare were established before and after the training. The participants reported a significantally improved confidence in their own role and the correct order of necessary procedures. The result reveals that the health professional reported a great need for training and supports further dissemination on this training methods in Norwegian primary health care.19

A cross-sectional analytic study to find risk of complications in a second pregnancy following caesarean section. The setting was on New south wales department of health, North Sydney, Australia. The samples are 136 101nwomen with one previous birth who gave birth to a singleton infant in 1998-2002.The result shows that 19% of the mothers had caesarean section in their first pregnancy. Compared with mother who had primary caesarean section and underwent labour in the second birth were increased risk of uterine rupture, post partum hemorrhage. For infant there was increased risk of preterm delivery and neonatal intensive care unit admission following labour in birth after primary caesarean section. The study reveals that the caesarean section in the 1 st pregnancy is being considered, particularly for elective caesarean section for non-medical reasons.20

A descriptive study to improve to improve the maternity emergency skills and knowledge of health services providers, without midwifery qualification in non-midwives at Institute of Advanced Studies,Charles Darvin University, Northern Territory Australia. The sample size was 175 participants to collect the information. 7 The study concluded that the course is an important strategy to improve the maternity services offered to women in remote Australia.21

A study to evaluate the percentage of emergency cesarean section within 30 minute interval between decision and incision time to evaluate morbidity associated with this time interval. The setting was on the department of obstetrics and gynecology, Gunderson clinic La Crosse. The samples was 75 patients under going emergency caesarean section. The study was concluded that there 605 of emergency caesarean section were began in less than 30 minutes. There is no significant difference in maternal morbidity associated with emergency caesarean section. The thirty minute interval is obtainable in the large number of patient but did not have a beneficial effect on neonatal morbidity. Other measurement of emergency preparedness should be considered other than 30 minutes. 22

A study to assess the changes in knowledge of midwifes and obstetricians following obstetrical emergency training. The setting of the study are the 6 Hospitals in south west of England, UK. The sample size was 22 junior and 23 senior doctors, 47 junior and 48 senior nurses, a total of 140 participants. The method used for collecting data is multiple choice questionare. The study concluded that practical multi professional, obstetrical emergency training increased midwives and doctors knowledge of obstetric emergency management. Further more, neither the location of training, in a simulation centre or in local Hospital, nor the inclusion of team work training made any significant difference to the acquisition of knowledge in obstetrical emergencies.23

A Study to assess the short course in maternity emergencies for remote are a health staff with no midwifery qualifications. The setting was on Institute of Advanced studies, Charles Darwin University, Northern Territory, Australia. The samples are the Remote area health providers. The study reveals that the course is an important strategy to improve the maternity services offered to women in remote Australia.24

A study to improving the hospital system for care of women with major obstetric hemorrhage. The setting was on Department of Obstetrics and Gynecology, New york, USA. The sample was staff nurses. The method used for the study is interview and gain a protocol for early diagnosis, assessment, and management of patients at high risk for major obstetrical hemorrhage. The result reveals that there were significant increases in cesarean birth between the periods of 2000-2001 and 2002-2005. There was a significant improvement in mortality due to hemorrhage when comparing 2000-2001 with 2002-2005. The study concluded that despite a significant increase in major obstetric hemorrhage cases, we found improved outcomes and fewer maternal death after implementing systematic necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage.25

8 6.3 OBJECTIVES OF THE STUDY:

1. To assess the knowledge of staff nurses regarding obstetrical emergencies.

2. To assess the knowledge of staff nurses regarding management of obstetrical emergencies.

3. To assess the practice of staff nurses regarding management of obstetrical emergencies.

4. To find out association between the knowledge and selected demographic variables of the staff nurses.

5. To find out association between the practice and selected demographic variable of the staff nurses.

6. To develop a self instructional module for staff nurse regarding obstetrical emergency protocol.

6.4 OPERATIONAL DEFINITION

1. Assessment- Assessment refers to the critical analysis and valuation or judgement of the status or quality of a particular condition or situation.

2. Knowledge- It is the staff nurses familiarity gained by experience regarding obstetrical emergencies and assess their intellectual ability by administrating questionnaire.

3. Staff nurse- Is a person, who has successfully completed Diploma Nursing Course from INC registered school of nursing and registered in the State Nursing Council.

4. Obstetrical emergencies – Obstetrical emergencies are the emergencies that occur during pregnancy and labour. It will affect the maternal outcome and foetal survival .

5. Practice- It the staff nurses skill for the management in obstetrical emergencies with their gained experiences.

6. Management: It is the staff nurses ability to deal effectively in emergency obstetrical care.

7. Protocols: The procedure of a hospital or health care facility to minimize the risk of obstetrical emergencies to patients or members of the staff.

6.5 HYPOTHESIS FOR THE STUDY:

9 H1. There will be statically significant association between knowledge regarding obstetrical emergencies and years of experiences. H2. There will be statically significant association between knowledge regarding obstetrical emergency and course attended regarding obstetrical emergencies

6.6 ASSUMPTIONS:

1. Staff nurses possess some knowledge on obstetrical emergencies management. 2. Staff nurses knowledge regarding obstetrical emergencies management can be measured by using a knowledge questionnaire.

6.7 DELIMITATIONS OF THE STUDY:

1. The study is limited to only staff nurses those who have completed General nursing and midwifery course. 2. The study is limited to staff nurses who working in Vanivillas hospital, Bangalore.

6.8 PILOT STUDY The study will be conducted with 6 samples. The purpose to conduct the pilot study is to find out the feasibility for conducting the study and design on plan of statistical analysis.

6.9 VARIABLES:

Variables are an attribute of a person or objects that varies, that is takes on different values. #Dependant variables: Knowledge level of staff nurses regarding management of obstetrical emergencies. #Independent variables: Age, General educational status, Course attended regarding obstetrical emergencies, Residential area, Present working ward and years of experience.

7.0 MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

The data will be collected from staff nurses working at Vanivillas hospital, Bangalore.

7.1.1 RESEARCH DESIGN:

10 Non-experimental design The research approach adopted for this study is descriptive in nature.

7.1.2 RESEARCH APPROACH:

Descriptive survey approach.

7.1.3 SETTING OF THE STUDY:

The study will be conducted at Vanivillas Hospital, Bangalore.

7.1.4 POPULATION All staff nurses who have passed GNM course and working in Vanivillas hospital, Bangalore.

7.2 METHODS OF DATA COLLECTION (INCLUDING SAMPLING PROCEDURE).

The data collection procedure will be carried out for a period of 1 months. The study will be conducted after obtaining permission from concerned authorities. The investigator will collect the data from staff nurses by using structured questionnaire to assess the knowledge and practice regarding obstetrical emergencies.

The structured questionnaire schedule consists of following sections. Section A: Questions related to demographic data. Sections B: Questions related to assess the level of Knowledge and practice regarding Obstetrical Emergencies. Section C: Observational check list to assess practice regarding obstetrical emergencies management.

7.2.1 SAMPLING TECHNIQUE Sampling technique adopted for selection of sample is non-probability convenient sampling.

7.2.2 SAMPLE SIZE

The samples consist of 60 staff nurses working in Vanivillas Hospital, Bangalore.

SAMPLING CRITERIA

11 7.2.3 INCLUSIVE CRITERIA

1. Nurses who have undergone General Nursing and midwifery course.

2. Nurses who are working in Vanivillas Hospital, Bangalore.

3. Nurses who are willing to participate in the study.

7.2.4 EXCLUSIVE CRITERIA

1. Nurses who are Graduates in nursing and postgraduates in nursing.

2. Nurses who are not available at the time of study.

3. Nurses who are not willing to participate in the study

7.2.5 TOOL FOR DATA COLLECTION 1. The structured questionnaire is used to collect the data from the staff nurses

7.2.6 DATA ANALYSIS METHOD

1. The data collected will be analyzed by using descriptive and inferential statistics. 1) Descriptive statistics: Frequency and percentage for analysis of demographic data and mean, mean percentage and standard deviation will be used for assessing the level of knowledge 2) Inferential statistics: Chi-square test will be used to find out the association between knowledge and selected demographic variables.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO THE PATIENTS OR OTHER HUMAN BEING OR ANIMALS?

1) Since the study is descriptive survey, interventions are not required

7.4 ETHICAL CLEARENCE

12 The main study will be conducted after the approval of research committee of the college. Permission will be obtained from the head of the institution. The purpose and details of the study will be explained to the study subject and assurance will be given regarding the confidentiality of the data collected.

8. LIST OF REFERENCE: [VANCOUVER STYLE FOLLOWED]

13 1. Curran CA, Clinical Nurse Specialists and associates, Intra partum emergencies. Obstetrics. Gynacolo. Neonatal Nursing. 2003 nov-dec; 32(6):802-13. Available from URL:http://www.pubmed.com. 2. Dutta DC, Text book of Obstetrics.6th edition; central publications: 2004. 3. Myles, Text book of midwives. 14th Edition; Churchill Livingstone Publications:China, 2004. 4. Onakewhor JU, Gharoro EP. Changing trends in maternal mortality in developing country. Niger J Clin Pract. 2008 Jun; 11(2): 111-20. Available from URL:http://www.pubmed.com. 5. Jegathy R. Sudden Maternal Death in Malaysia: A case report. J. Obstet. Gynacol Research 2002. Aug; 28(4): 186-93. Available from URL: http://www.pubmed.com. 6. Park K. Text book of Preventive and Social Medicine.18th Edition. Banarsidas Bhanot Publishers: Jabalpur,2005. 7. Chaudharian, Pal S, Roy A. Mortality pattern in babies delivered by cesarean section and vaginal delivery. Indian Paediatrics 1989 March; 26(3):247-50. Available from URL:http://www.pubmed.com. 8. Saizonouz J, Godin I, Oueado EM, Zerbo R, Dujardin B. Emergency Obstetrical care in Benin referral hospitals: ‘Near miss patients’ views. Trop Med Int. Health,2006 may; 11(5): 672-80. Available from URL: http://www.pubmed.com. 9. Pitchforth E, Van Teijlingen E, Graham W, Dixon-woods M, Chowdhury M. Getting women to hospital is not enough: A qualitative study of acess to emergency obstetric care in Bangladesh. Qual Saf Health care. 2006 Jun; 15(3): 214-9. Available from URL: http://www.pubmed.com. 10. Nancy Burns, Susan K. Grove. Understanding Nursing Research. Seond Edition: Saunders publications: 2002. 11. Brich L, Jones N Doyle PM, Green P, Mc Laughlin A , Champney C, Williams D, Gibbon K, Taylor K. Obstetric skill drill: Evaluation of teaching methods: Nurse educ. Today. 2007 Nov; 27(8): 915-22. Epub 2007 Mar 21. Available from URL: http://www.pubmed.com. 12. Black RS, Brockle hurst P. A systemic review of training in acute obstetric emergencies. Bjog. 2003 sep; 110(9): 837-41. Available from URL:http://www.pubmed.com. 13. Maslovitz S, Baskai G, Lessing JB, Ziv A, Many A. Recurrent Obstetric management mistakes identified by simulation. Obstet. Gynecol. 2007 Jun; 109(6): 1295-300. Available from URL:http://www.pubmed.com. 14. Johanson RB, Menon V, Burns E, Kargaramanya E, Osipov V, Israelyan M, Sargsan K, Dobson S, Jones P. Managing Obstetrical Emergencies and Trauma (MOET) structured skill training in Armenia, Utilizing models and reality based scenarios. BMC Med Educ. 2002 May 20;2:5. Available from URL: http://www.pubmed.com. 15. Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, Whitelaw A. Does training in obstetric emergencies improve neonatal outcome. BJOG. 2006 Feb; 113(2): 177-82. Available from URL: http://www.pubmed.com. 16. Obi SN, Ozumba BC, Okaro JM. Obstetric referrals at a university teaching hospital. East Afr. Med. J. 2001 May; 78(5): 262-4. Available from URL:http://www.pubmed.com. 14 17. Gau ML, Chung UL, Kao CH, Wu SF, Kuo SC,Long A. A survey of obstetricians willingness to practice collaboratively with midwives.J Nurs Res.2002 Sep;10(3):205-16. Available from URL: http://www.pubmed.com. 18. Crofts JF, Bartlett C, Ellis D, Hunt LP, Fox R, Draycott TJ. Training for shoulder dystocia: A trial of simulation using low-fidelity and high-fidelity mannequins.Obstet. Gynecol.2006 Dec; 108(6): 1477-85. Available from URL: http://www.pubmed.com. 19. Utsi R, Brandstop H, Johansen K, wisborg T, training in multiprofessional emergency medicine in Primary Health Care. Tidsskr Nor Laegeforen. 2008 may 1;128(9): 1057-9. Available from URL:http://www.pubmed.com. 20. Taylor LK, Simpson JM, Roberts CL, Olive Ec, Henderson-smart DJ. Risk of complications in a second pregnancy following caesarean section in the first pregnancy. Med J Aust. 2005 Nov 21;183(10):515-9. Available from URL: http://www.pubmed.com. 21. Kildea S, Kruske S, Bowell L. Maternity Emergency Care: Short course in maternity Emergencies for remote area health staff with no midwifery qualification. Aust. J. Rural Health. 2006 Jun; 14(3): 111-5. Available from URL:http://www.pubmed.com. 22. Schauherger CW, Rooney BL, Beguin EA, Schaper AM, Spindler J. Evaluating the thirty minute interval in emergency cesarean sections. J AM Coll Surg. 1994 Aug; 179(2):151-5. Available from URL: http://www.pubmed.com. 23. Crofts JF, Ellis D, Draycott TJ, Hunt LP, AKANDE VA. Change in knowledge of midwives and obstetricians following obstetric emergency training. BJOG. 2007 Dec; 114(12):1534-4. Epub 2007 Sep 27. Available from URL:http://www.pubmed.com. 24. Kildea S, Kruske S, Bowell L. Maternity emergency care:Short course in maternity emergencies for remote area health staff with no midwifery qualifications. Aust J Rural Health. 2006 Jun; 14(3)111-5. Available from URL: http://www.pubmed.com. 25.Skupski DW, Lowenwirt IP, Weinbaum FI, Brodsky D, Danek M, Eglinton Gs. Improving hospital system for the care of women with major obstetric hemorrhage.Obstet Gynacol.2006 May; 107(5): 977-83. Available from URL: http://www.pubmed.com.

9. Signature of the candidate 15 10. Remarks of the guide

11. Name and designation of

11.1 Guide

11.2 Signature

11.3 Co-guide(if any)

11.4 Signature

11.5 Head of the department

11.6Signature

12. 12.1 Remarks of the Chairman and principal

12.2 Signature